Order your FREE, in-home colorectal cancer screening test.

Are you at risk for colorectal cancer?

Every 4 minutes someone is diagnosed with colorectal cancer. In that same amount of time, you can answer 8 quick questions to see if you qualify for a FREE, in-home screening test.
Do you live within a 50 mile radius of Goshen, Indiana? *

Yes No

Are you between the ages of 45-74? *

Yes No

Have you had a colonoscopy in the last 10 years? *

Yes No

Do you have a personal history of colorectal cancer? *

Yes No

Do you have a family history of colorectal cancer? *

Yes No

Do you have a history of polyps? *

Yes No

Do you have a personal history of inflammatory bowel disease (Crohn’s disease or ulcerative colitis)? *

Yes No

Do you have active bleeding? *

Yes No

Pat yourself on the back! You made your health a priority by taking the time to join our “movement” and learn about your risk for colorectal cancer.

Based on the information you provided, you are at average risk of colorectal cancer, so a screening kit may be beneficial to you.

If you have any questions regarding your results, please discuss them with your primary care doctor. Need a primary care physician? We can help you find one.

Please visit GoshenHealth.com or call (574) 364-2496, Mon-Fri from 8:00 a.m. – 4:30 p.m. to learn more about Goshen Health doctors, services and locations.

Click NEXT to order your FREE in-home screening test.

Full Name *

First Name Last Name

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number *

Area Code Phone Number

E-mail

Your date of birth: *

Month Day Year

Are you male or female? *

Male Female

Please list the first name of your primary care provider (physician, nurse practitioner or physician assistant). If you do not have a primary care provider, please mark NA. *

Please list the last name of your primary care provider (physician, nurse practitioner or physician assistant). If you do not have a primary care provider, please mark NA. *

Please list the office number of your primary care provider. If you do not have a primary care provider, please mark NA. *

Please indicate your selection below: *

I give permission for my screening results to be sent to my physician or PCP, if they are a member of a Goshen Health Medical Home or ACO. I give permission for the Goshen Health screening program to follow-up with me if I did not list a physician or PCP.

Thank you for making your health a priority and joining our "movement" to learn about your risk for colorectal cancer. Click "Submit" to see if you qualify for a FIT screening test.
Should be Empty: